The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Monitor heart rhythm.

Auscultate lung sounds.

Assess capillary refill.

Obtain vital signs.

Answer and Explanation

The Correct Answer is B

A. Monitor heart rhythm: While cardiac monitoring is important, it doesn’t directly assess airway status or ventilation. Respiratory compromise must be identified through airway-focused assessments.
B. Auscultate lung sounds: Hourly lung auscultation helps detect early signs of airway obstruction, stridor, or atelectasis. It’s the most direct way to monitor for post-extubation respiratory issues.
C. Assess capillary refill: Capillary refill assesses peripheral perfusion but gives little information about airway patency or breathing effectiveness after extubation.
D. Obtain vital signs: Vital signs are useful but may not change until respiratory compromise becomes severe. Lung assessment provides earlier clues of deterioration.

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Correct Answer is C

Explanation

A. Notify the physician: There is no immediate need to notify the provider since the heart rate is above the standard threshold for withholding digoxin. Clinical parameters are still within safe limits for administration.
B. Recheck the apical pulse in 30 minutes: Rechecking later may delay necessary therapy without cause. The heart rate is currently adequate, and there is no indication of bradycardia or instability.
C. Administer the digoxin: Digoxin is generally held if the apical heart rate is below 60 beats/minute in adults. Since the pulse is 62 and the client’s baseline is slightly higher, it is safe to administer the medication while continuing to monitor for any signs of bradycardia.
D. Hold the digoxin: Holding the dose is unnecessary unless the heart rate falls below 60 or there are signs of toxicity. In this case, the current rate does not warrant withholding the drug.

A. Physical activity B. Drawing C. Therapeutic communication D. Medication administration

Correct Answer is D

Explanation

A. Physical activity: Exercise may help reduce stress and improve overall well-being, but it does not directly target the positive symptoms of schizophrenia such as hallucinations or delusions.
B. Drawing: Art therapy can support emotional expression and reduce anxiety, but it is more beneficial for promoting general mental health and coping, not specifically controlling positive symptoms.
C. Therapeutic communication: Communication techniques are crucial for building trust and ensuring safety, but they are not sufficient on their own to manage hallucinations, delusions, or disorganized thinking.
D. Medication administration: Antipsychotic medications are the primary treatment for managing positive symptoms of schizophrenia. They help reduce hallucinations, delusions, and thought disturbances by modulating neurotransmitter activity in the brain.

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The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?

Correct Answer is C

Explanation

Which nursing action is most helpful in managing the positive symptoms of schizophrenia?

Correct Answer is D

Explanation

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